A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?
Delayed gastric emptying
Pulmonary edema
An upper respiratory infection
Atelectasis
The Correct Answer is D
A. Delayed gastric emptying is not associated with decreased breath sounds in the lower lobes of the lungs. It is more commonly associated with gastrointestinal symptoms such as bloating and nausea.
B. While pulmonary edema can cause respiratory symptoms, such as crackles and wheezes, decreased breath sounds in the lower lobes are not typically indicative of pulmonary edema. Pulmonary edema is more commonly associated with fluid accumulation in the lungs, leading to crackles and other signs of fluid overload.
C. An upper respiratory infection primarily affects the upper airways, such as the nose and throat, and typically presents with symptoms such as nasal congestion, sore throat, and cough. It is not typically associated with decreased breath sounds in the lower lobes of the lungs.
D. Atelectasis refers to the collapse or closure of a part of the lung, leading to decreased air entry and breath sounds in the affected area. In a client who has been on bedrest for several days, atelectasis can occur due to reduced lung expansion and ventilation. Decreased breath sounds in the lower lobes are a common finding in atelectasis, especially when the condition affects the bases of the lungs, as gravitational forces can exacerbate the collapse of lung tissue in dependent areas. Therefore, this finding is most consistent with atelectasis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "There is no way to predict how long it will last in each individual client." This response acknowledges the variability among individuals but does not provide specific information about urinary frequency during pregnancy. While it's true that the duration of urinary frequency can vary from person to person, the response lacks guidance or reassurance for the client.
B. "It occurs during the first trimester and near the end of the pregnancy." This response correctly identifies the pattern of urinary frequency during pregnancy. Urinary frequency is common during the first trimester due to hormonal changes and the growing uterus pressing on the bladder. It may also occur near the end of pregnancy as the fetus descends into the pelvis, putting pressure on the bladder again.
C. "In most cases it only lasts until the 12th week, but it will continue if you have poor bladder tone." This response suggests that urinary frequency typically resolves by the 12th week of pregnancy but may persist if the client has poor bladder tone. While urinary frequency may improve for some women after the first trimester, attributing its continuation solely to poor bladder tone oversimplifies the issue.
D. "It’s a minor inconvenience, which you should ignore." This response minimizes the client's concerns and does not provide helpful information about urinary frequency during pregnancy. Urinary frequency can be distressing for some pregnant individuals and should not be dismissed as a minor inconvenience.
Correct Answer is A
Explanation
A. "I will be sure to take the albuterol before taking the cromolyn": Taking albuterol before cromolyn is the correct sequence because albuterol is a bronchodilator that helps open the airways quickly, while cromolyn is a mast cell stabilizer that helps prevent asthma symptoms. Taking albuterol first allows for better penetration of cromolyn into the airways. Therefore, this statement indicates an understanding of the appropriate sequence for using the medications.
B. "I will use both medications immediately after exercising": While it is essential to use albuterol before exercise to prevent exercise-induced bronchospasm, using cromolyn immediately after exercise is not typically indicated. Cromolyn is more effective when used prophylactically to prevent asthma attacks triggered by allergens or exercise rather than as an acute rescue medication.
C. "If my breathing begins to feel tight, I will use the cromolyn immediately": Cromolyn is not indicated for the immediate relief of acute bronchospasm. It works best when used regularly to prevent asthma symptoms rather than as a rescue medication during an asthma attack. Albuterol is the appropriate choice for immediate relief of tightness or wheezing.
D. "I will administer the medications 10 minutes apart": While it's important to space out the administration of different medications to ensure proper absorption and effectiveness, the specific timing between albuterol and cromolyn may vary based on individual instructions from the healthcare provider. Generally, it's recommended to take albuterol first, followed by cromolyn after a brief interval.
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